Social inequality is reflected most harshly in our chances to lead a healthy life, argues Esme Choonara. But the fight for better healthcare rests in the fundamental way our society is organised
The Covid-19 pandemic has shone a spotlight on the devastating health inequalities faced by working class people and in particular those from Black, Asian and other minority ethnic backgrounds. It has also revealed how decades of underfunding, understaffing and privatisation have undermined our NHS. So although our health, or lack of it, may sometimes feel very personal, it is clearly shaped by social and economic factors including housing, income, working conditions, discrimination and pollution levels.
Even access to outdoor space, which has become so important to our mental health under lockdown, is determined by class and ethnicity — with an Office of National Statistics report in May showing that black people are four times more likely to report having no access to a garden, patio or balcony. Much of the way that health and illness are talked about under capitalism is reductive — focusing either just on the biology of a particular disease, or on an individual’s behaviour or lifestyle “choices”. The pursuit of profit that has undermined the NHS doesn’t just affect the resources that are allocated to healthcare, it also shapes how healthcare is structured, who has access to it, and the ideas that underpin it. The scandalous role big pharmaceuticals play in limiting and controlling development and access to drugs illustrates this.
In the 1990s there was a breakthrough in the treatment of HIV/AIDS, with the development of an effective combination of antiretrovirals that transformed the impact of the disease. However, due to drug patents, and therefore the cost of the medication, it took another eight years and hundreds of thousands of deaths in the Global South for that medication to become accessible in poorer countries. It is feared that this same scenario will play out with any Covid-19 vaccine developed. As Science Magazine points out, “Money and national interests may win out. The United States and Europe are placing advance orders for hundreds of millions of doses of successful vaccines, potentially leaving little for poorer parts of the world”.
Distorted Some of the drugs now being considered already have patents attached to them. There are patents on respirator masks — the company 3M has over 400 of these — that make it harder to reproduce PPE in the quantities and quality needed globally. Medical research is constantly distorted by competition — most notably between private firms and labs, but also sometimes between competing charities, academic institutions and NGOs. It is useful to understand public healthcare as a compromise between competing class interests.
Historically good standards of healthcare have been won by struggles of working people. But a healthy workforce is also needed to sustain profits. That focus on keeping people functional for work influences many of the assumptions about what healthcare should be for, and shapes a narrow approach to medical problems. Of course, the vast majority of doctors and other healthcare workers don’t go into medicine because they want to help capitalist exploitation or because they want to fix people just so they can get back to work. But most health workers operate within a biomedical framework which often neglects to ask what the person they are treating actually wants from their care, and ignores the wider social factors that impact on health and wellbeing.
We experience health and healthcare provision via a very hierarchical model, both in regard to staff hierarchies and patients. Most often it is still the case that the “doctor knows best” while the patient must listen gratefully to what they are told and follow instructions. Patients are often described as “non-compliant” by medical professionals if they don’t follow their allotted treatment plan or take their medications as they are told — a very loaded way of thinking about the relationship between a health worker and a patient. There have been many challenges to this way of thinking among health workers and in public policy over the past two decades with attempts to refocus on “person-centred care” and on shared decision making, but in the majority of cases this remains an aspiration. Notions of empowering and involving patients are pretty meaningless without adequate resources that can offer genuine choices.
We should also be wary of a neoliberal version of empowering service users by recasting them as consumers, or as individual commissioners of services — for example through personal care budgets. These policy devices have often themselves left many facing crises when the services they need are just not available. None of this should be seen as a critique of genuine medical advance. When necessary, fixing people through surgery, medication or other procedures is the right thing to do, so advances in medical treatment are to be welcomed.
But treatments are not equitably available either in the UK or globally, and advances in medical treatment are also shaped by the limitations, priorities and fragmentation of research and development funding. The dominant trend amongst drug companies currently is towards merger and acquisitions, with fewer and fewer bigger and bigger drugs companies forming, whilst at the same time closing down research departments. Increasingly profits derive from price hikes following merger whilst research is outsourced to universities and other bodies once a profitable treatment area offers itself. Astrazenica’s collaboration with Oxford University to develop the first Covid-19 vaccine is a case in point. One of the clearest ways to understand how capitalist values shape health care is the way in which older people and those with disabilities have been treated during the current crisis. These groups are dismissed and discriminated against as they are not seen as productive to capitalism.
Tony Abbott, the former Australian prime minister recently appointed by Boris Johnson as a UK trade envoy, illustrates the opinion of many of the political class when he attacked what he called Covid-19 “health dictatorships”, saying the economic cost of lockdowns meant families should be allowed to consider letting elderly relatives with the coronavirus die by letting nature take its course. He claimed it was costing the Australian government as much as £110,000 to give an elderly person an extra year’s life, substantially beyond what governments would usually pay for life-saving drugs. Abbott said not enough politicians were “thinking like health economists trained to pose uncomfortable questions about the level of deaths we might have to live with”.
His views echoed those of The Daily Telegraph journalist Jeremy Warner who described the pandemic as a useful “cull” of older people. At the beginning of the pandemic, the daily death toll was accompanied by constant reassurance that those that had died were elderly or had “underlying health problems” — as if this somehow explained or excused their deaths. The government has also wilfully neglected the safety of residents and staff in care homes — not even initially counting deaths in care homes in the official figures. The argument that an aging population is a costly burden on society has its roots in the Thatcher-Regan era of political reaction and anti-working class offensives. In 1987 Daniel Callahan wrote a book called Setting Limits where he argued that healthcare should be rationed by stopping access to life-extending treatments when someone reaches a particular age. Interestingly, he didn’t apply this theory to himself when he needed expensive cardiac treatment while in his seventies.
We need to oppose the use of “ageing population” arguments. Socialists should insist that older people are part of our community and are valuable, a social resource, in and of themselves. Older people have contributed in many ways at different points in their lives both economically and socially. In the 21st century they continue to contribute, as carers for family members and grandchildren, as well as through the sharing of experiences and knowledge. Another manifestation of the disregard for older people and those with disabilities is the way in which Do Not Resuscitate notices have been misused during the pandemic. In April, the Guardian reported that a Welsh GP surgery had written to patients with certain medical conditions, urging them to sign a form saying they did not want resuscitating in order that “scarce ambulance resources can be targeted to the young and fit who have a greater chance”.
The National Institute for Health and Care Excellence has been forced to change new guidelines on who should receive critical care during the pandemic after campaigners pointed out that its original guidance automatically placed people with autism or learning disabilities high on a frailty score, and therefore less likely to receive critical care, regardless of their actual physical health. The reason older people and those with disabilities are discriminated against in this way is because they are not seen as economically functional and therefore useful to capitalism. This turns the problem on its head.
The reason why many who would like to work don’t is because society, and especially the world of work, is organised in such a way to exclude or marginalise people with health problems, impairments or disabilities. For example, the reason why the employment rate of people with learning disabilities has rarely been above 10 percent since records began is not because people with learning disabilities don’t want to work or aren’t capable — copious research disproves both of these notions — it is because employers don’t consider them economically viable. Health is predominantly socially determined. Consequently, it is wrong to blame individuals for their own health problems. Public health agendas which moralise about diet, exercise and addiction, linking them to an amorphous concept of “health behaviours” deny any context and ignore how and the extent to which inequality and stress impact on individuals’ lives. Biomedical model solutions to health problems are sold back to us as health commodities, with constant pressure on us as individuals to make ourselves better, healthier people.
Even the recognition of the need for a more holistic approach to health is sold back to us through the Wellness industry — where we are encouraged to buy the right diet or exercise plans or find the right lifestyle coach. Wellbeing programmes are also becoming common in workplaces — offered by employers as a way to offset the stress of modern employment practices. We shouldn’t dismiss the activities that help people to deal with stress and distress — many people find yoga, pilates, meditation or other physical exercise helpful — but we should point out that none of these actually address the structural causes of stress at work and at home that are built into our lives. Alongside wellness, we have seen an increasing emphasis on us taking responsibility to develop “resilience”. A doctor recently told me how fed up she is of being told to improve her resilience putting the focus on her as an individual to come to terms with the stress of dealing with patients, their illnesses and problems every day. Solutions cannot be simply about individuals.
Solutions must be collective and holistic. Interestingly, research conclusively shows that collective social activism actually boosts feelings of wellbeing and vitality — so as far as wellbeing solutions go, activism should be a highly recommended activity! A wider view of health is needed and a drastic change to how the NHS is funded, structured and run. But the NHS alone can’t deal with all the social determinants of health or address the racism, and exploitation that create the tragic health inequalities that have been exposed by the pandemic.
We should remember that the health inequalities we face in the UK are even starker in the Global South — which has been ravaged by neoliberal structural adjustment programmes, debt, climate change, hunger and displacement. Health justice has to include all of those in need around the globe. In 1948, the World Health Organisation defined health as “a state of complete physical, social and mental well-being and not merely the absence of disease or infirmity”. This laudable approach cannot be delivered by a global system focused on the pursuit of profit. In the here and now, we must fight for vital resources for our healthcare system, for an end to privatisation, and for a more holistic approach to healthcare. In the longer term, we need a society focused on social needs.
Esme Choonara is a health worker